Get a (LTC) Quote

Burling Insurance Group Long Term Care can suggest a long term care (LTC) insurance plan that’s right for you. We will work with you to choose insurance coverage based on your care preferences, the benefits you would like to receive and the amount of coverage you can afford.

This is not the application. Answering the questions on this form will not result in a determination of your eligibility for coverage.

After a consultation with an LTC Specialist, you will be able to determine which coverage is best for you and we will assist you through the application process. For help on a question you do not understand, please feel free to call us at 1-877-582-2732.

We are asking for personal information because there are many discounts available that can reduce the cost of your long-term care insurance.

For example, insurers offer substantial discounts to married couples. A discount may be available when only one spouse obtains coverage. Some insurers offer discounts to partners or individuals living together.

Business owners may be able to deduct the cost of long-term care insurance, and even cover spouses. Some states offer tax credits.

LTC insurance varies state to state. Please enter your home address to, so we may provide accurate information.

Are you a Business Owner or Self-Employed?

Yes - Business Owner

Yes - Self-Employed

No

Marital (Household) Status*

Single

Married

Domestic Partner

Live with another

Date of Birth (Applicant)*

MM

DD

YYYY

Date of Birth (Spouse or Partner)

MM

DD

YYYY

Occupation

Most financial advisors suggest that you should not spend more than 5-7% of your annual income on long term care. Please consider your annual income. Is it:

Under $20,000

$20,000 - $30,000

$30,000 - $50,000

$50,000 - $100,000

Over $100,000

Which type of coverage would you prefer?

Nursing Home Care Only

Home and Community Care Only

Comprehensive Nursing Home Care with Home and Community Care

I’m Not Sure

With a longer waiting period, your annual premium will be less expensive. However, your out of pocket expenses will increase. According to Genworth Financial’s 2017 Cost of Care Survey, the average daily cost for a private nursing home room is $267. With this in mind, how long can you afford to pay out of pocket before benefits are paid?

0 days

30 days

60 days

90 days

180 days

365 days

I'm not sure.

The average stay in a nursing home is 2.3 years (MetLife marketing survey, 2012). However, this does not include the home health care that you may receive prior to entering a nursing home. How long would you like to have your benefits last? If you live alone, have a history of longevity in your family, have a history of chronic illness or Alzheimer’s disease, are a woman, or own your own business, you may want to consider a longer benefit period.